Stenting Carotid Arteries Risky for Seniors

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This meta-analysis suggests that carotid endarterectomy and stenting seem to work equally well in younger patients in expert hands.

In the elderly, however, endarterectomy has better outcomes with low morbidity, mortality, and stroke rate.

Carotid endarterectomy and carotid stenting to treat carotid disease worked equally well in younger patients, but in elderly patients endarterectomy was associated with a lower risk of stroke, a meta-analysis showed.

Carotid stenting was associated with an increased risk of stroke in elderly patients compared with younger patients (odds ratio [OR] 1.56, 95% CI 1.40-1.75), according to George A. Antoniou, MD, PhD, of the Hellenic Red Cross Hospital in Athens, Greece, and his co-authors.

Patients who'd undergone endarterectomy, on the other hand, had equivalent cerebrovascular outcomes whether they were old or young (OR 0.94, 95% CI 0.88-0.99), they wrote online October 23 in JAMA Surgery. Endarterectomy did carry a heightened mortality risk in elderly patients, however (OR 1.62, 95% CI 1.47-1.77).

Among other findings were that the peri-interventional mortality risks associated with stenting were similar in old and young patients (OR 0.86, 95% CI 0.72-1.03). And the incidence of myocardial infarction (MI) was higher in older patients who underwent endarterectomy and stenting (OR 1.64, 95% CI 1.57-1.72 and OR 1.30, 95% CI 1.16-1.45, respectively).

One significant limitation of the study was that studies included in the analysis used different cutoff ages to define the "elderly" category. "Some studies defined elderly as those patients older than 65 years, whereas others used 80 years or older as the cutoff," the authors wrote.

Overall, however, the conclusions of the study are in line with "what most of us have seen in randomized, prospective studies," such as the recently published Carotid Revascularization Endarterectomy vs Stenting Trial (CREST), wrote R. Clement Darling III, MD, in an accompanying editorial.

In that study, elderly patients undergoing endarterectomy fared well with regard to stroke, transient ischemic attack (TIA), or both. "Conversely, those elderly patients undergoing carotid stenting had a higher incidence of stroke, TIA, or both," he said.

Mortality was slightly higher in elderly patients undergoing endarterectomy vs stenting in CREST (0.5% vs 0.4%). "But the clinical significance of such a difference is doubtful," said Darling. The incidence of MI in CREST was also higher in patients undergoing endarterectomy than stenting (2.2% vs 1.4%), and MI was more common in older patients than younger ones.

The current study reflects an ongoing debate about the safest and most appropriate treatment for carotid disease in the elderly, wrote Antoniou and his co-authors.

While the more recent and less invasive innovation of stenting might seem like a more suitable treatment for an elderly population at high risk of surgical complications, wrote the authors, some studies have indicated an increased risk of cerebrovascular complications in this population.

To make matters more confounding, patients over age 80, who are at high risk of stroke and could benefit from carotid intervention, were excluded from some of the early landmark trials.

One explanation for the elevated stroke risk in elderly patients undergoing stenting is their "unfavorable anatomy," the authors wrote. Elderly patients, they said, are more likely to have heavily calcified and tortuous supra-aortic branches, and adverse morphological changes to the aortic arch.

These characteristics may make wire manipulation more difficult and may result in a higher risk of endothelial trauma and clot dislodgement, they said. But the risks associated with these challenges may be lessening as techniques and tools improve, the authors wrote.

More recent studies of stenting using more modern endovascular technology and cerebral protection devices have indicated equivalent results in both older and younger patients, they said. And a meta-regression analysis of the current study found that, in the more recent studies included in this trial, the log odds ratio for stroke and mortality in stenting decreased.

"This essentially means that in older studies (old devices, inexperience with the stenting technique, and initial phase of the learning curve) the difference in stroke or mortality is large, becoming less as the years pass, and this reduction in difference is statistically significant," the authors wrote.

Ongoing technological advancements with newer generation stents and embolic protection devices, as well as growing expertise with stenting, may help circumvent the current limitations of stenting in elderly patients, wrote the authors.

There were other limitations, beyond age categorization, in the study. There were variations in the surgical techniques used in the studies, said the authors. And some studies included in the analysis were limited by poor case selection and exposure of the study sample.

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